Uncomplicated cyclical breast pain and acute urinary tract infection can frequently be managed with self-care, supported by advice from community pharmacy. Steve Titmarsh explains…

Breast pain (mastalgia) can be cyclical (associated with hormonal fluctuations of the menstrual cycle) or non-cyclical, associated with injuries to the neck, shoulder or back; conditions such as mastitis or breast abscess; pregnancy; the menopause, and some medicines such as the contraceptive pill, certain antidepressants and some herbal medicines such as ginseng.^1,2,3

Cyclical breast pain is common, affecting up to two-thirds of women, with moderate to severe pain experienced by 10%.⁴ It is most often experienced among women aged 30 to 50 years.⁴ Symptoms usually start with two weeks of a menstrual period and improve as the period begins. The pain is dull, heavy or aching and usually affects both breasts. It may extend to the armpits.⁴

Non-cyclical breast pain can be constant or intermittent and can affect just one breast or one area of a breast. It is more often seen in women aged over 40 years.⁵

Pain not originating from the breasts can be mistaken for breast pain – there can be a number of causes. For example, a pulled muscle, costochondritis (inflammation of the cartilage attaching the ribs to the sternum), Tietze’s syndrome (similar to costochondritis but rarer and associated with chest swelling that can be present after any pain and tenderness have resolved),⁶ a soft tissue injury or fracture of a rib or vertebra.

Fibromyalgia, herpes zoster or referred pain from cardiac or gastrointestinal disorders may also be to blame.^3,4

Treatment

If other causes are excluded (eg cancer, pregnancy, infection such as mastitis and breast abscess, or cysts) mild symptoms of cyclical breast pain may not need medical treatment. For some women (around 1 in 5) symptoms may spontaneously resolve within three to six months: evidence suggests that breast pain may go within three months in about 30% of women, although it may reappear in about two thirds of cases.⁷

Supporting breasts with a good fitting bra can help relieve symptoms – wearing it 24 hours a day for a week before a period.^5,7

Paracetamol, ibuprofen or topical nonsteroidal anti-inflammatory drugs may be beneficial.^5,7 Sometimes other medication may be implicated such as the contraceptive pill or hormone replacement therapy, so changing a drug thought to be the cause may be beneficial.^5,7

Research suggests evening primrose oil is unlikely to be effective. However, some women do find it helps. It can take up to four months to have any impact on symptoms.⁵ Around half of the cases of non-cyclical breast pain resolve spontaneously; treatment response tends to be poor and the underlying cause needs to be treated.⁸ Severe or persistent pain will need specialist medical treatment.⁷

When to refer – breast pain¹

People with the following symptoms should be referred for urgent medical attention:

• breast pain and fever or feeling hot and shivery
• any part of the breast is red, hot or swollen
• a hard lump in the breast that does not move around
• nipple discharge, which may be streaked with blood
• change in shape of one or both breasts
• dimpled skin (orange peel-like) on the breast
• a rash on or around the nipple, or the nipple has sunk into the breast
• family history of breast cancer^5,7
• signs of pregnancy such as a missed period^5,7

Lower urinary tract infection

Lower urinary tract infection (UTI) – cystitis – is a result of bladder infection, most often caused by bacteria from the gastrointestinal tract. In 70–95% of cases the infecting organism is Escherichia coli, candida species are rarely the culprit.⁹

It is common – affecting almost a third of women at least once by the time they are 24 years old.⁹

Cystitis can happen over and over in young and pre-menopausal women as a result of sexual intercourse, past history of UTI in childhood or family history. In postmenopausal and older women a history of UTI before menopause; urinary incontinence; atrophic vaginitis; cystocele; increased post-void urine volume; urine catheterisation, and reduced functional status in elderly institutionalised women, may increase the risk of recurrence. Cystitis recurs in around 20–30% of women who have had a UTI.⁹ Diabetes, catheterisation and pregnancy can also increase the risk of UTI.^5,7

Symptoms

Typically, uncomplicated UTI will be associated with pain on urination – described as discomfort, burning, tingling or stinging. Women may report urinating more frequently than usual or an urgent need to urinate that results in incontinence. Urine can appear cloudy or a different colour and can be smelly. Blood may be present in the urine making it look red or brown coloured or the blood itself may even be visible. Women may also complain of having to urinate at night more often than usual.⁹

When to refer – urinary tract infection^9,10,11

Women should be referred for medical attention if they have:

• blood in the urine (haematuria)
• pain between the hips and just below the ribs
• rigors – shivering with a fever but feeling cold
• nausea
• vomiting
• altered mental state
• worsening symptoms or symptoms not responding within 48 hours of starting antibiotics
• not responded to several courses of treatment or preventive measures.

Treatment

In most cases acute, uncomplicated UTI will clear in less than a week with or without treatment – it often clears in just over three days if treated with a suitable antibiotic.⁹

For women who are not pregnant or catheterised and have no blood in their urine pain caused by cystitis can be relieved with paracetamol. It is important to keep hydrated by drinking plenty of fluids (ideally six to eight glasses a day), but cranberry drinks or products that alkalinise the urine should not be recommended.^9,12 An information leaflet can be downloaded from the Royal College of General Practitioners website.¹²

Sometimes an antibiotic may be necessary depending on the severity of symptoms, risk of complications and previous antibiotic use. Nitrofurantoin or trimethoprim are first choice. A three-day course is often effective.⁹

Prevention

There are some things that women who have recurrent cystitis can do for themselves that may help reduce the risk of further infections, including:¹¹

• drinking about two litres of liquid each day
• only using gentle, plain soap to wash the genital area to try not to upset the balance in the bacterial flora
• avoiding using bubble baths, talcum powder, deodorants and feminine wipes around the genitals
• not shaving or waxing close to the vaginal and urethral openings
• postmenopausal women may benefit from a vaginal oestrogen pessary or cream
• not delaying urination and urinating promptly after sex.⁹

Advice on vaginal dryness

“It’s extraordinary that there are so many vaginal moisturisers without a shred of clinical trial evidence,” says Dr Karen Gardiner from Hyalofemme distributor Purple Orchid Health.

“This is a sensitive area of the body. It merits special care. Every woman deserves an assurance that the products they use have been properly tested, and cancer patients in particular need to take care.

“They may endure more severe vaginal dryness symptoms and may be advised not to use anything containing hormones, perfumes or parabens. Labelling and marketing statements can be confusing. 

“Products can be sold as moisturisers when they are only lubricants, some latch on to ingredients which may have particular properties, but the formulation as a whole is untested. 

“Hyalofemme is the only non-hormonal vaginal moisturiser with peer-reviewed, published clinical studies proving its safety and efficacy in a range of patient cohorts including menopausal women, those who recently had babies, and cancer patients.”

References

1. NHS.UK. Breast pain (www.nhs.uk/conditions/breast-pain; accessed May 2023).
2. Breast Cancer Now (https://breastcancernow.org/information-support/have-i-got-breast-cancer/benign-breast-conditions/breast-pain; accessed May 2023).
3. Breast Cancer Care. Breast Pain (www.bradfordhospitals.nhs.uk/wp-content/uploads/2019/02/bcc71_breast_pain_2018.pdf; accessed May 2023).
4. Clinical Knowledge Summaries. Breast pain – cyclical (https://cks.nice.org.uk/topics/breast-pain-cyclical; accessed May 2023).
5. Patient.info. Breast Pain (https://patient.info/womens-health/breast-problems/breast-pain; accessed May 2023).
6. NHSinform. Costochondritis (www.nhsinform.scot/illnesses-and-conditions/muscle-bone-and-joints/conditions/costochondritis; accessed May 2023).
7. Patient.info. Breast pain: Causes symptoms and treatment (https://patient.info/doctor/breast-pain-pro; accessed May 2023).
8. Goyal A. Breast pain. BMJ Clin Evid 2011;2011:0812.
9. Clinical Knowledge Summaries. Urinary tract infection (lower) – women (https://cks.nice.org.uk/topics/urinary-tract-infection-lower-women; accessed May 2023).
10. Patient.info. Urinary tract infection in adults (https://patient.info/doctor/urinary-tract-infection-in-adults; accessed May 2023).
11. British Association of Urological Surgeons (BAUS). Self-help information for women with recurrent cystitis (www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/Recurrent%20cystitis.pdf; accessed May 2023).
12. Royal College of General Practitioners. Treating your infection – urinary tract infection (UTI) (https://elearning.rcgp.org.uk/mod/book/view.php?id=12652; accessed May 2023).